1. Medication Administration Part II Stephanie Stevens MSN,RN,CNE

2. Routes of Administration— Oral Route Oral Route Given by mouth (po) and swallowed with liquid Given by mouth (po) and swallowed with liquid images.jupiterimages.com/.../10/16/23421610.jpg

3. Routes of Administration— Oral Route Oral Route Sublingual (SL) Sublingual (SL) Placing the medication under the tongue Placing the medication under the tongue Should NOT be swallowed, chewed Should NOT be swallowed, chewed www.suboxone.com

4. Routes of Administration— Oral Route Buccal Buccal Placing solid medication against the mucous membranes against the cheek or under lip until dissolved Placing solid medication against the mucous membranes against the cheek or under lip until dissolved Patient Education Patient Education Alternate cheeks with each dose to avoid irritation Alternate cheeks with each dose to avoid irritation Do not chew, swallow the medication Do not chew, swallow the medication No intake of liquids No intake of liquids

5. Oral Medications Aspiration Aspiration Occurs when food, fluid, or medication intended for the GI route enters the respiratory tract. Occurs when food, fluid, or medication intended for the GI route enters the respiratory tract. Always evaluate your patient’s ability to swallow Always evaluate your patient’s ability to swallow Proper positioning will assist in preventing aspiration Proper positioning will assist in preventing aspiration Fowler’s position or seated position Fowler’s position or seated position Lateral position (when swallow, gag, and cough reflexes are intact) Lateral position (when swallow, gag, and cough reflexes are intact) Trouble swallowing? Trouble swallowing? May need consult (Speech therapy) May need consult (Speech therapy) Use other routes, (IV, SC) if possible Use other routes, (IV, SC) if possible May administer through NG or feeding tube May administer through NG or feeding tube

6. Routes of Administration— Parenteral Injecting a medication into body tissues Major routes include Subcutaneous (SQ) Subcutaneous (SQ) Intramuscular (IM) Intramuscular (IM) Intravenous (IV) Intravenous (IV) Intradermal (ID) Intradermal (ID)

7. Topical Medication Application Skin Protect hands by wearing gloves Apply to clean, dry, hairless, intact skin. Lotions, Creams, Ointments Lotions, Creams, Ointments Transdermal Medications Transdermal Medications

8. Topical Medication Application Eye Instillation Types of Ophthalmic Meds Types of Ophthalmic Meds Eye drops Eye drops Ointments Ointments Problems for Older Adults Problems for Older Adults Hand tremors Hand tremors Poor vision Poor vision Poor grasping Poor grasping Improving Compliance Improving Compliance Demonstrating each step and return demonstration Demonstrating each step and return demonstration

9. Topical Medication Application Eye Instillation Principles of Eye Instillation Principles of Eye Instillation Avoid instilling any form of eye medication directly onto the cornea. Avoid instilling any form of eye medication directly onto the cornea. Avoid touching the eyelids or other eye structures with eye droppers or ointment tubes Avoid touching the eyelids or other eye structures with eye droppers or ointment tubes Use eye medication only for the patient’s affected eye Use eye medication only for the patient’s affected eye NEVER allow a patient to use another patient’s eye medication NEVER allow a patient to use another patient’s eye medication

10. Topical Medication Application Nasal Instillation Nasal instillations come in: Nasal instillations come in: Sprays Sprays Drops Drops Tampons Tampons

11. Topical Medication Application Ear Instillation Internal ear structures are very sensitive to temperature extremes Internal ear structures are very sensitive to temperature extremes Use sterile ear drops Use sterile ear drops Do not occlude the ear with the dropper or irrigating syringe Do not occlude the ear with the dropper or irrigating syringe Straighten ear canal according to age of patient. Straighten ear canal according to age of patient.

12. Topical Medication Application Vaginal Instillation Foams, Jellies, Creams, Suppositories Foams, Jellies, Creams, Suppositories Administer with applicator Administer with applicator Usually patients prefer to self- administer, but if required by nurse, use gloves. Usually patients prefer to self- administer, but if required by nurse, use gloves. With any vaginal medication… With any vaginal medication… Perineal pad may be desired Perineal pad may be desired May have a foul odor May have a foul odor Allow perineal hygiene often Allow perineal hygiene often

13. Topical Medication Application Rectal Instillation “Bullet shaped”, thinner than vaginal suppositories “Bullet shaped”, thinner than vaginal suppositories Rounded end and lubrication- prevents anal trauma during insertion Rounded end and lubrication- prevents anal trauma during insertion Do not force into a mass of fecal material Do not force into a mass of fecal material Local or systemic effect Local or systemic effect Stored in refrigerator until given Stored in refrigerator until given

14. Inhaled Medications Respiratory tract- large surface area for absorption Respiratory tract- large surface area for absorption Readily absorbed and work fast—vascularity Readily absorbed and work fast—vascularity Can have local or systemic effect Can have local or systemic effect Essential for patient to learn proper use of inhaler. Essential for patient to learn proper use of inhaler.

15. Medication Administration—Parenteral Administration of meds by injection Administration of meds by injection -Considered an invasive procedure—use aseptic technique -Risk of infection -Injections requires certain skills to ensure safe administration -Effects of this route are rapid— depending on the rate of absorption. Close observation is imperative Close observation is imperative

16. Medication Administration— Parenteral Syringes Syringe Parts Syringe Parts Only touch the outside of the syringe barrel and the handle of the plunger!!! DO NOT touch the shaft of the plunger and the needle—risk of infection. Only touch the outside of the syringe barrel and the handle of the plunger!!! DO NOT touch the shaft of the plunger and the needle—risk of infection.

17. Medication Administration—Parenteral Types of Syringes Standard Can be 3-, 5-, 0r 10-mL May be supplied with or without needles Usu. calibrated in increments of 0.2 mL Insulin Calibrated in units of insulin Can be 0.5 – or 1 mL syringe Used only to administer insulin Tuberculin 1 mL syringes calibrated with 0.01 markings Used for skin testing May also be used for SQ, e.g. heparin

18. Medication Administration— Parenteral Needles Attached or unattached to syringes Attached or unattached to syringes Has 3 parts, which fits onto the hub of the syringe Has 3 parts, which fits onto the hub of the syringe -Hub (fits on tip of syringe) -Hub (fits on tip of syringe) -Shaft (connects to the hub) -Shaft (connects to the hub) -Bevel (slanted tip) has narrow slit that quickly closes after removing the needle to prevent leakage of med. -Bevel (slanted tip) has narrow slit that quickly closes after removing the needle to prevent leakage of med.

19. Medication Administration— Parenteral Needle Length Vary in length—0.4 in. to 3 in. Vary in length—0.4 in. to 3 in. Length is determined by: Length is determined by: Size of patient Size of patient Weight Weight Route of administration Route of administration

20. Medication Administration— Parenteral Needle Gauge Gauge – inside diameter of needle lumen Gauge – inside diameter of needle lumen Gauges are numbered 14 to 30. Gauges are numbered 14 to 30. Needles with the smallest gauges are labeled with the largest number. Needles with the smallest gauges are labeled with the largest number. Selection of gauge dependent upon: Selection of gauge dependent upon: Patient comfort Patient comfort Viscosity of fluid Viscosity of fluid Speed of administration Speed of administration

21. Medication Administration— Parenteral Preparing Injections from Ampules Contains single doses of medication Contains single doses of medication Use filter needle when aspirating (drawing up) medication into a syringe. Use filter needle when aspirating (drawing up) medication into a syringe.

22. Medication Administration— Parenteral Preparing Injections from a Vial Vials –single or multi-dose container that has a rubber seal at the top Vials –single or multi-dose container that has a rubber seal at the top Air needs to be injected because it is a closed system. Air needs to be injected because it is a closed system. Can be liquid or powder Can be liquid or powder Medications that are unstable in solution are packaged dry. Medications that are unstable in solution are packaged dry. The vial label specifies the solvent or diluent needed to prepare or reconstitute a desired medication concentration The vial label specifies the solvent or diluent needed to prepare or reconstitute a desired medication concentration Common diluents-normal saline, sterile distilled wate r Common diluents-normal saline, sterile distilled wate r

23. Medication Administration— Parenteral Mixing Medications Medications can be mixed—if they are compatible Medications can be mixed—if they are compatible Most nursing units have charts that list meds that are compatible Most nursing units have charts that list meds that are compatible May need to consult a pharmacist May need to consult a pharmacist

24. Medication Administration—Parenteral Mixing Medications What if… What if… Mixing one med from vial and other from ampule? Mixing meds from two vials? Mixing meds from two vials?

25. Medication Administration— Parenteral Preparing Insulin Therapy When preparing U-100 insulin, use a U- 100-unit-scaled syringe. When preparing U-100 insulin, use a U- 100-unit-scaled syringe. Always have a second nurse double-check insulin for right drug, dose, etc. Always have a second nurse double-check insulin for right drug, dose, etc. Gently roll (not shake) all cloudy insulin for resuspension of insulin. Gently roll (not shake) all cloudy insulin for resuspension of insulin.

26. Medication Administration— Parenteral Preparing Insulin Therapy Mixing two types of insulin in a syringe Mixing two types of insulin in a syringe Prepare the short-acting insulin first, then the intermediate acting Prepare the short-acting insulin first, then the intermediate acting Other principles to consider when mixing insulins Do not mix insulin with other medications or diluents unless approved by prescriber Do not mix insulin with other medications or diluents unless approved by prescriber

27. Administering Injections— Ways to Minimize Discomfort Change needle after drawing up medication Change needle after drawing up medication Position the patient so that muscle tension is decreased. Position the patient so that muscle tension is decreased. Use Z-track method when administering irritating meds Use Z-track method when administering irritating meds

28. Administering Injections— Ways to Minimize Discomfort Divert patient’s attention—talk to the patient Divert patient’s attention—talk to the patient Insert the needle QUICKLY and SMOOTHLY to minimize tissue pulling Insert the needle QUICKLY and SMOOTHLY to minimize tissue pulling Hold the syringe barrel steady while the needle remains in tissues Hold the syringe barrel steady while the needle remains in tissues Inject the medication SLOWLY and STEADY. Inject the medication SLOWLY and STEADY.

29. Administering Medication— Subcutaneous Injections Subcutaneous or SC/SQ Injection of medication into the loose connective tissue under the dermis Injection of medication into the loose connective tissue under the dermis Has slower absorption rate than IM Has slower absorption rate than IM

30. Administering Medication— Subcutaneous Injections Subcutaneous Sites (preferred or best sites) Subcutaneous Sites (preferred or best sites) Outer posterior aspect of the upper arms Outer posterior aspect of the upper arms Abdomen below the costal margins to the iliac crest and 2” in. away from the umbilicus Abdomen below the costal margins to the iliac crest and 2” in. away from the umbilicus Anterior aspects of the thighs Anterior aspects of the thighs -Recommended site for heparin injections is the abdomen. -Recommended site for heparin injections is the abdomen. Low molecular weight heparin - right or left side of the abdomen. Give 2” from the umbilicus Low molecular weight heparin - right or left side of the abdomen. Give 2” from the umbilicus

31. Administering Medication— Subcutaneous Injections Other SC sites for other medications Other SC sites for other medications Scapular areas of the upper back Scapular areas of the upper back Upper buttocks Upper buttocks Using the right equipment Using the right equipment U-100 insulin syringe for insulin U-100 insulin syringe for insulin Tuberculin syringe for heparin Tuberculin syringe for heparin Injection sites Injection sites Rotating injections within the same body part for a sequence provides more consistency in the absorption of insulin. Rotating injections within the same body part for a sequence provides more consistency in the absorption of insulin. Fastest to slowest absorption sites= abdomen → arms → thighs → buttocks Fastest to slowest absorption sites= abdomen → arms → thighs → buttocks

32. Administering Medication— Subcutaneous Injections Give only small doses -Amount of dose 0.5-1.0ml Patient’s body weight indicates the depth of the SC layer -Amount of SQ tissue determines angle of administration -Amount of SQ tissue determines angle of administration

33. Administering Medication— Intramuscular Injections Provides faster absorption than SC Provides faster absorption than SC Uses a longer and larger gauge needle than SC Uses a longer and larger gauge needle than SC Administer IM injections so that the needle is perpendicular to the patient’s body—as close as 90 degree angle as possible Administer IM injections so that the needle is perpendicular to the patient’s body—as close as 90 degree angle as possible

34. Administering Medication— Intramuscular Injections S ites S ites Consider the following Consider the following Area free from infection or necrosis? Area free from infection or necrosis? Any localized bruising or abrasions? Any localized bruising or abrasions? Location of the underlying nerves, bones, major blood vessels? Location of the underlying nerves, bones, major blood vessels? Volume to be administered? Volume to be administered? Each site has certain advantages and disadvantages Each site has certain advantages and disadvantages

35. Administering Medication— Intramuscular Injections Ventrogluteal Ventrogluteal -Bony Landmarks -Bony Landmarks Greater trochanter Greater trochanter Anterior superior iliac spine Anterior superior iliac spine Iliac crest Iliac crest

36. Administering Medication— Intramuscular Injections Vastus lateralis Vastus lateralis Bony Landmarks Bony Landmarks Greater trochanter Greater trochanter Patella of knee Patella of knee

37. Administering Medications- Intramuscular Injections Rectus femoris Rectus femoris Bony Landmarks Bony Landmarks Anterior superior iliac spine Anterior superior iliac spine Patella of knee Patella of knee

38. Administering Medication— Intramuscular Injections Dorsogluteal Dorsogluteal Bony Landmarks Bony Landmarks Greater trochanter Greater trochanter Posterior superior iliac spine Posterior superior iliac spine Iliac crest Iliac crest

39. Administering Medication— Intramuscular Injections Deltoid Deltoid Bony Landmark Acromium process

40. Administering Medication— Intramuscular Injections Z-Track Method Recommended to use when giving IM medications that are irritating Recommended to use when giving IM medications that are irritating Select site. Pull the overlying skin and SC tissue at least 1inch laterally to the side with the non-dominant hand. Select site. Pull the overlying skin and SC tissue at least 1inch laterally to the side with the non-dominant hand. Hold the skin in this position until you administer the injection. Hold the skin in this position until you administer the injection. After preparing the site with alcohol pad, inject the needle deep into the muscle and slowly inject the medication if no blood return on aspiration After preparing the site with alcohol pad, inject the needle deep into the muscle and slowly inject the medication if no blood return on aspiration Hold 10 seconds, then withdraw the needle and release the skin Hold 10 seconds, then withdraw the needle and release the skin

41. Administering Medication— Intradermal Injections Usually used for skin testing (diagnostic ) Usually used for skin testing (diagnostic ) Medication is usually potent—inject into the dermis, where there is reduced blood supply Medication is usually potent—inject into the dermis, where there is reduced blood supply Assess: Assess: Site for changes in color and tissue integrity. Site for changes in color and tissue integrity. Best to choose a site lightly pigmented, free of lesions and relatively hair free Best to choose a site lightly pigmented, free of lesions and relatively hair free Best sites - upper back, upper arms, and inner forearms Best sites - upper back, upper arms, and inner forearms

42. Administering Medication— Safety Devices Most frequent route of exposure to blood- borne diseases is from needle-stick injuries Most frequent route of exposure to blood- borne diseases is from needle-stick injuries However, over 80% are preventable with implementing safe needle devices However, over 80% are preventable with implementing safe needle devices Syringes Syringes Special design—has sheath or guard that immediately covers the needle after it is withdrawn from the skin, reducing the risk of injury Special design—has sheath or guard that immediately covers the needle after it is withdrawn from the skin, reducing the risk of injury Disposal of both in a receptacle—red sharps container; DO NOT RECAP! Disposal of both in a receptacle—red sharps container; DO NOT RECAP! Use these whenever possible to reduce injury Use these whenever possible to reduce injury